BV update: eliminating diagnostic confusion
In the absence of universally accepted data, 3 leading authorities review the evidence on bacterial vaginosis and discuss their approaches to diagnosing and treating this common vaginal affliction.
Dr. Faro: When we see a woman with recurrent BV, we base our treatment on the premise that this is an ecological situation and not an infection. We then try to change the pH using Aci-jel and boric acid suppositories. Currently, we’re looking at some buffering agents in clinical studies. In addition, we also ask the patient not to have sexual intercourse because, as Dr. Ledger suggested, the male ejaculate can have a tremendous impact on the vaginal ecosystem. If we’re fortunate to get the pH down below 4.5, we usually see a correction. In instances where we’re having difficulty getting the pH down, we will go to an antibiotic, such as oral metronidazole.
When examined microscopically, normal discharge contains only 1 dominant form of bacteria—Lactobacillus.
OBG Management: Once a patient has been treated, what is the best way to determine normal vaginal microflora? When is she in the clear, so to speak?
Dr. Faro: We go back and do a pH and microscopic analysis. If a physician relies solely on a whiff test, he or she is going to be in error because many ladies will have a pH that is 5 or greater and not have BV. This is because the flora has shifted and is now dominated by other bacteria. The pH is key for us because if it has not gone below 4.5, we know there’s still a problem.
Dr. Hillier: The most underutilized test in women’s health today is the vaginal pH. The easiest way to determine whether there has been reestablishment of Lactobacillus-pre-dominant flora is to measure vaginal pH. A vaginal pH of less than 4.7 indicates a predominance of vaginal lactobacilli.
Dr. Ledger: I’d like to stress here that, despite dozens of articles and hundreds of chapters in medical textbooks, physicians should not diagnose BV with a culture. They often will get a report showing the presence of Gardnerella. The problem is that Gardnerella can be present in the vagina of normal people and in women who have been successfully treated. A standard culture will not identify the number of anaerobic bacteria.
OBG Management: Women often experience a certain amount of discharge. What would you consider normal?
Dr. Faro: Normal discharge is white to slightly gray in color, odorless, and has a pH of 3.8 to 4.2. When you look at it microscopically, the squamous cells are well-estrogenized and white blood cells are rare. Also, you see only 1 dominant form of bacteria: large rods. When you culture this, it will be Lactobacillus. If you do the microbiology, you’ll find other bacteria, but their counts are 10 to 3 or lower per milliliter of fluid. Lastly, the amount of discharge a woman has is also related to her hormonal status.
OBG Management: A recent study conducted by the CDC found that many women still douche despite the fact that clinicians do not support the practice. In fact, douching has been linked to the development of BV. What should physicians recommend to their patients?
Dr. Ledger: I would not advise a patient to douche. However, I don’t believe that douching is a risk factor for BV. Rather, sexual intercourse and exposure to the male ejaculate are such culprits. Retrospective epidemiological studies have linked douching to BV. But these same analyses overstated the risk of infection with regard to intrauterine devices, as indicated in a recent study from Mexico City.15 While it is said that douching lowers the number of good lactobacilli in the vagina, over-the-counter antifungal agents have the same impact on vaginal lactobacilli. Further, the absence of lactobacilli in postmenopausal women is not uniformly associated with BV. The danger of douching is when women who have been exposed to bacterial agents delay medical care because of this primary intervention method.
Dr. Hillier: There is definitely a link between douching and acquiring BV. We think that douching can deplete the beneficial Lactobacillus from the vagina, especially those with unstable flora. We routinely counsel the women who come to our clinic to avoid douching.
Dr.Faro: Many of my patients have been douching for years—more than 10 to 20 years—and have experienced problems with vaginitis. This practice has been going on for several generations. Patients who have never douched are discouraged from beginning such a practice because it presents no benefits and there is the possibility of an adverse reaction. However, it would be difficult to get women who have not had an adverse effect to douching to discontinue a practice that has been an integral part of their hygienic practices.
